Patient's First Name Patient's Last Name Phone Date of Birth Address City State Zip Email SSN We currently use an automated system to send you text messages, emails and voice recordings for appointment reminders and notifications about glasses and contact lenses. Check this box if you prefer to not to use this system: Don't UseOccupation Employer Hobbies Emergency Contact Name / Phone How did you hear about us? Are we using vision insurance for your visit? Yes NoIf you checked YES, who is the responsible party for billing any insurance copays, overages or non-covered services? Self Spouse ParentIf you checked SPOUSE or PARENT, please provide their contact information:First Name Last Name Address Phone Date of Birth SSN or Member ID Number Date of last eye exam Date of last medical exam Do you have allergies (environmental, drug, etc.)? No YesIf YES, explain List all medications (with dosages) Do you use tobacco products? No YesIf YES, type/amount/how long? Do you drink alcohol? No YesIf YES, type/amount/how long? Do you use illegal drugs? No YesIf YES, type/amount/how long? This information is kept strictly confidential. However, check here if you prefer to discuss your social history directly with the doctor. Discuss with DoctorSocial History Description Note any family history [parents, grandparents, siblings, children (living or deceased)] and indicate maternal or paternal.Blindness Yes No Blindness Relationship Cataract Yes No Cataract Relationship Crossed Eyes Yes No Crossed Eyes Relationship Diabetes Yes No Diabetes Relationship Detached Retina Yes No Detached Retina Relationship Glaucoma Yes No Glaucoma No Relationship Heart Disease Yes No Heart Disease Relationship High Blood Pressure Yes No High Blood Pressure Relationship Macular Degeneration Yes No Macular Degeneration Relationship List any of the following you have had: crossed eyes, lazy eye, drooping eyelid, glaucoma, retinal disease, cataracts, eye infections, eye injuries, refractive surgeries (such as LASIK) Do you currently have, or have you ever had, any problems in the following areas? Please check all that apply:Eyes Blurred Vision Halos Peripheral Vision Loss Double Vision Dryness Mucous Discharge Redness Itching Excess Tearing Glare or Light Sensitivity Eye Pain or Soreness Flashes or Floaters Tired EyesBones, Joints, Muscles Rheumatoid Arthritis Muscle Pain Joint PainNeurological Headache Migraines SeizuresPsychiatric Anxiety Depression Memory TroubleEars, Nose, Mouth, Throat Allergies Sinus Congestion Runny Nose Dry ThroatRespiratory Asthma EmphysemaLymphatic/Hematologic AnemiaIf you selected any of the above, or have a condition not listed, please explain: Condition Explanation I consent to the use and disclosure of my health information for purposes of treatment, payment, and healthcare operations. I certify that the information given by me in applying for insurance and/or Medicare payment is true and correct. I authorize my doctor to act as my agent in helping me to obtain payment of my insurance benefits.Signature Date If signing as a personal representative of the patient, describe the relationship to the patient and the source of authority to sign this form.Print Name Relationship to Patient Note: Please allow up to 10 seconds for the form to submit.